Job Description
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first.We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. This position is remote. The Clinical Pharmacist I is responsible for reviewing coverage determinations and appeals to ensure clinical appropriateness and compliance with CMS regulations and plan benefits for Alignment Health Plan (AHP) members. This role serves as a subject matter expert in Part D coverage determinations, redeterminations, and Part C organizational determinations. In addition, the Clinical Pharmacist I conducts Medication Therapy Management (MTM) activities, including comprehensive medication reviews (CMRs) and targeted interventions, with a focus on high-risk members to improve adherence, reduce high-risk medication utilization, and enhance overall quality of care for AHP members. The Clinical Pharmacist I supports additional managed care functions and projects as assigned. Job Responsibilities: Drive Accurate and Timely Part D Coverage Decisions: Review and render Part D coverage determination and appeal requests, applying clinical judgment against plan benefits and CMS requirements to render compliant decisions. Collaborate with medical directors by providing appropriate clinincal information needed to perform clinincal reviews per the guidelines. Deliver Medication Therapy Management Services: Conduct comprehensive medication reviews via telephone for members enrolled in the MTM program, identifying drug therapy
